Category Archives: Patient-Centered

To engage staff in its patient experience improvement action plan, UnityPoint Health defined four foundational behaviors expected of every team member (not just providers) across the organization.

In this podcast, Paige Moore, director of patient experience at UnityPoint Health, describes the rationale and rollout for the four behaviors, which are based on patient and visitor feedback and comments.

Specialists working day to day with primary care medical homes will move more easily into the role of patient-centered medical home neighbor (PCMH-N) than those who have not, notes Robert Krebbs, WellPoint’s director of payment innovation. WellPoint recently launched a medical neighborhood pilot for three specialties with clear care coordination alignment opportunities with primary care medical homes.

The neighborhood model requires education on the part of specialists and patients who have not been part of integrated delivery systems so they can better benefit from the new patient-centered medical world, Krebbs explains in this audio interview.

Although initally challenging, the engagement of specialists in Blue Cross Blue Shield of Michigan’s medical home program generated several outstanding primary care-specialist collaborations that improved care coordination and reduced unnecessary utilization and spend related to difficult-to-manage patients, notes Donna Saxton, field team manager for BCBSM’s value partnerships program.

A pioneer since 2005 in the development of outcomes-based measures to evaluate patient care, BCBSM based its standards on the Chronic Care Model. Today, the payor acts as a resource for other medical home recognition and accreditation efforts.

Despite the migration of some Pioneer ACOs to CMS’s Medicare Shared Savings Program (MSSP), expect the surge in commercial accountable care organizations to continue in 2014, predicts Steven Valentine, president, The Camden Group. In this audio interview, Valentine suggests improvements to patient handoffs, an area in which ACOs have disappointed, in Valentine’s view, as well as expectations for the other much-modeled care delivery platform, the patient-centered medical home (PCMH).

In both the ACO and the PCMH, Valentine anticipates specialists will be critical parts of the solution, especially when it comes to emerging payment models, quality and performance.

There’s education, there’s experience, and then there’s the ‘right stuff’  the indefinable personality traits that earmark an individual as a change agent, collaborator and ambassador of case management, says Annette Watson, senior vice president of community transformation for Taconic IPA (TIPA), of TIPA’s requirements for the RN case managers it hires for its advanced patient-centered medical homes.

Then there are the not insignificant contributions of the RN case manager to accountable and patient-centered care, which Ms. Watson describes in this interview.

While staff-buy-in and communication continue to challenge the embedded case manager model, the participant in CMS Innovation Center’s Comprehensive Primary Care (CPC) initiative says reimbursement for embedded case management is less of an obstacle today than in the past, due to funding-friendly care models and pilots descending from healthcare reform.

Primary care and the patient-centered medical home offer a great opportunity for health coaches to become allies with patients in improvement of their health, notes William Appelgate, executive director of the Iowa Chronic Care Consortium. Individuals with the highest health risks should be given priority, but those on the cusp of a serious health event also merit coaching assistance, he says. For providers new to the coaching conversation, Appelgate shares three benefits of incorporating health coaches in the care process  including the upping of their ‘outcomes game.’

Although the healthcare industry is well-acquainted with the patient-centered medical home, the model is still quite new and novel to patients, notes, Jay Driggers, director of consumer engagement at Horizon Blue Cross Blue Shield of New Jersey. In this interview, Driggers describes what’s at stake when moving from a reactive provider model to a proactive model.